Ranks of primary-care docs begin to grow, efforts pay off

Rebecca Lavender M.D. first considered becoming a primary-care physician shortly after earning her undergraduate degree at the University of Rochester. She was volunteering at the time for AmeriCorps HealthCorps in Berkeley, Calif., helping to connect uninsured families with health care.

The Penfield native's career path came into sharper focus when she became a medical assistant at a community health clinic in the Bay Area.

"And I think through that I really got a taste of what a medical home and primary-care physician can actually do for a patient when you have a good relationship," says Lavender, a family medicine resident at the University of Rochester Medical Center who cooks and watches baseball in her spare time.

Ongoing efforts at the medical center to increase the ranks of primary-care doctors also resonated with Lavender. Her primary-care clerkship with a URMC-affiliated internist, for instance, confirmed in her mind that she had chosen the right profession.

"I think you can't choose what you fall in love with in medicine," Lavender says. "And I'd rather do primary care and, unfortunately, get paid less and love my job."

She adds, "I think it's a real challenge for (indebted) graduates, but I think, hopefully, the pendulum is swinging back" toward widespread improvement of the profession's reimbursement rates and work-flow challenges.

URMC officials are pouring considerable time and resources into making sure that Lavender is not alone in her passion for primary-care medicine. The results have been favorable so far, though challenges remain, including the impending retirement of some of the busiest local doctors in the field.

Primary-care doctors are flowing into the area primarily through two residencies at URMC: family medicine and meds/peds. The latter program prepares doctors to treat adults and children as a result of training in both internal medicine and pediatrics.

Those two residencies typically graduate a total of 20 physicians, says Wallace Johnson M.D., director of URMC's Center for Primary Care and a general internal medicine physician who practices at a URMC office in Fairport.

"We're talking about 20 people, of which probably two-thirds go into primary care in Rochester," says Mark Taubman M.D., dean of the UR School of Medicine and Dentistry. "That's a lot."

Though they have the option of pursuing specialties, "we're starting to see people go into primary care from our internal medicine residency program that we didn't see before, and the same thing is true with pediatrics," Taubman says.

The primary-care network at URMC and Highland Hospital has made recent strides in physician recruitment, Johnson says. Eight doctors came on board this year; seven did so in 2011. The network now has 108 doctors who are family physicians, med/peds physicians or general internists working at 23 area offices.

Given the progress, Rochester does not have a shortage of primary-care doctors currently, Taubman says. The supply has been stable partly because of a four-pronged approach that began with leaders from the local hospital system and Excellus BlueCross BlueShield sitting down to assess the situation more than three years ago, he says.

"There are a few stresses to the situation in that it's become clear that a lot of the primary-care practices are largely full and that there are decreasing new visits, and that is usually a sign that we need more docs," Taubman says. "So we did an analysis and concluded that we need to add a net of about 80 primary-care doctors to support the Greater Rochester area, which is not a huge amount."

"So first of all, I think, compared to a lot of other communities, we are less stressed in terms of primary care," he adds. "And there's some good reasons for that, and one of which is we've done well compared to our peers, particularly in New York, in keeping people in the region."

According to the most recent available data from the Monroe County Medical Society and Finger Lakes Health Systems Agency, Monroe County had 1,039 primary-care doctors in 2009, says MCMS executive director Nancy Adams. The broader area-defined as Monroe, Livingston, Ontario, Wayne, Seneca and Yates counties-had 1,234 primary-care physicians.

In recent months, the medical society has fielded many calls from individuals who cannot find a local primary-care practice that is accepting new adult patients, Adams says. Pediatric and OB/GYN primary-care practices generally have not had access issues, she adds.

Area residents are flocking to urgent care centers, Adams says. Yet the exact reasons for the surge are not clear-cut, given that some people may be seeking the convenience of after-hours care.

Federal and state data, however, show mounting primary-care shortages across New York. Adding the equivalent of 388 full-time practitioners, including physicians, nurse practitioners, physician assistants and midwives, would solve the problem, according to the U.S. Department of Health and Human Services' Office of Shortage Designation. Roughly 791 more full-time people would achieve a 2,000-1 ratio of population to providers in the affected areas.

A July 2012 report from the Center for Health Workplace Studies at SUNY College at Albany's School of Public Health shows that more than 3.9 million New Yorkers live in a federally designated primary-care shortage area due to geography, low income or Medicaid eligibility. The report maintains that the scarcities exist in areas of the city of Rochester, rural northwest Monroe County, eastern Ontario County, all of Orleans County and other parts of the region.

Primary care still has the stigma of long hours and lower pay, but "we've got some exciting projects going on in the Rochester area," including the Rochester Medical Home Pilot Initiative, Adams says.

Funded in part by Excellus and based on an approach that establishes a long-term relationship between patients and a provider team, the pilot program aims to "equip primary-care offices with the ability to do more community-based care management, particularly for chronic-disease patients," Johnson says. The effort goes a long way to prevent hospital readmissions, he adds.

"What this means from an infrastructure point of view is you need very good health information technology and staff members whose specific job is care coordination and data management, tracking whether referrals are followed through, whether health maintenance procedures such as colonoscopies are obtained, whether important lab results come back or not," Johnson says.

Other measures include having registered nurse care managers focus on recently hospitalized patients and chronic-disease patients, as well as changing primary-care payment models to help primary-care doctors "get off the hamster wheel of visit-driven business and focus more on coordination of care," Johnson says.

He adds, "That's the bugaboo for primary care and what is somewhat disenchanting still to medical students, that it's an entirely fee-for-service, visit-driven business across America."

A loan forgiveness program financed through a nominal surcharge on Excellus commercial member inpatient claims at Highland, Strong, Unity and Rochester General hospitals, with the backing of the Rochester Business Alliance, also has made a difference in the effort to stabilize the supply of primary-care doctors, Taubman says.

"In fact, two of the eight people (URMC) recruited this year stayed here because of the loan forgiveness," he says.

While initiatives and collaborations have strengthened the local ranks of primary-care doctors, mentorship sometimes makes all the difference.

When initially charting his career path, Louis Papa M.D., partner at the Olsan Medical Group and professor of clinical medicine at URMC, had planned to be a research oncologist focused on developing tumor vaccines. He decided to invest his ambitions in primary care instead, after connecting with a local internist widely known for his teaching and approach to outpatient medicine.

Papa says he has no regrets.

"I'm very happy with what I do; every day is a (positive) challenge," he says. "I get to know the patients over the course of their life."